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PERMITTEE NAME/ADDRESS (/nc(ude Facility NamelLocation iJDifferenq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCNARGE MONITORING REPORT (DMA)
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<br />^ PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 0' 07 O 1 TO 0 (? 3 !`
<br />Fonn Approved.
<br />OMB No. 2040-0004 `
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<br />(5~13~; MC) '
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER ICendy under penalty of law that this documern end all anachmenLS were TELEPHONE DATE
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<br />VCS submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE r/
<br />TYPED OR PRINTED lam aware that there are significant penaltles for submitting false information, OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br /> includin the ossibili of line end im risonment br knowin violations.
<br />UUMMtN I J ANU hXYLANAI ION Uh AN7 VIVLA I IVN.J (FfelereDCe all aRdCnmenl5 nereJ
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<br />EPA Fo ~pXT.-,(REV 3/99) Previous editions may be used. THIS I A -PART FORM PAGE OF
<br />,. 00142/000717-1~a~ 1
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